- Independent hospital
Practice Plus Group Hospital - Emersons Green
Assessment report published 20 October 2026
Contents
Ratings - Surgery
Our view of the service
We carried out an unannounced, comprehensive 2-day assessment on 30 June and 1 July 2026.
We carried out the assessment as the provider had not been inspected under our new methodology. The service was last inspected in 2016 where the service was rated good in all key questions across all assessment service groups, except effective, which was not rated under our previous methodology.
Safe:
People were protected from avoidable harm and the service maintained a good standard of safety. Systems and processes supported safe care, including effective referral, transfer and discharge arrangements, safeguarding processes, good medicines management and effective infection prevention and control measures. Staffing levels met patients’ needs and staff received training for their role. However, we identified some areas for improvement, including inconsistencies in risk assessment documentation in theatres, concerns from some staff about reporting culture and some staffing pressures during patient transfers. There were environmental risks relating to storage and security of hazardous substances, variation in resuscitation equipment, and some gaps in policy oversight. Leaders had recognised many of these issues and had taken action or developed plans to address them.
Effective:
People's needs were assessed and care was delivered in line with best practice, resulting in positive outcomes and experiences. Staff completed thorough assessments, personalised care planning and multidisciplinary reviews to ensure people's needs were understood and met. Care was delivered by suitably skilled staff working collaboratively across services, and outcomes were monitored through audits, patient-reported outcome measures and governance processes, with evidence of improvements in function, pain and quality of life. Patients told us they were involved in decisions about their care and knew what to expect throughout their treatment. However, there were some areas for improvement, including low appraisal compliance in theatres, some evidence of teams working separately from one another within theatre without collaboration, and inconsistent participation in national audit programmes. Overall, the service provided effective care and treatment.
Caring:
People were treated with kindness, compassion and respect and were involved in decisions about their care and treatment. Patients consistently provided positive feedback about staff, describing them as caring, supportive and responsive to their needs. Staff understood and accommodated people's individual needs and preferences, including communication, cultural and additional support needs, and promoted choice, independence and dignity throughout the care pathway. Patients told us they felt listened to, informed and supported. However, some staff described concerns about wellbeing, morale and support from senior leaders. Despite this, people's experiences of care were consistently positive and the service remained caring overall.
Responsive:
People could access care in ways that met their individual needs and preferences. The service made reasonable adjustments for people with additional needs, provided information in accessible formats and used effective communication support, including interpretation services. Care was coordinated across teams to promote continuity, and patients told us the service was accessible, responsive and easy to use. Feedback was actively sought and used to improve services, and patients consistently reported positive experiences. However, some patient information leaflets were out of date. Most patients did not experience delays and waiting times for referral to treatment standards met the NHS target set. Overall, the service provided responsive and person-centred care.
Well-led:
The service rating for well-led has changed from good to requires improvement. Leadership and culture did not always support high-quality, person-centred care. While staff generally felt supported by immediate managers, senior leaders were not always perceived as approachable, responsive or receptive to concerns. Some staff reported bullying, favouritism, inconsistent treatment and fear of repercussions for raising issues. Freedom to Speak Up processes were established and well understood, but staff confidence in being heard remained variable, particularly within theatres. Staff were not always clear on the organisation's vision and values. Governance arrangements were generally effective, with clear accountability structures, risk management processes and audit systems supporting service quality and sustainability. The service demonstrated a strong commitment to equality, diversity and inclusion, and worked effectively with partners and local communities. However, opportunities for learning, innovation and continuous improvement were not fully embedded, with staff not always feeling involved in improvement activity and limited evidence of research or innovation.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
Or, if we have requested an action plan, this will be requested upon publication of the final report.
People's experience of this service
People spoke positively about their experiences of the service and consistently described staff as kind, compassionate, professional and responsive. One patient told us staff were “polite and friendly”. Patients told us they were treated with dignity and respect, felt listened to, and were involved in decisions about their care and treatment. They said assessments were thorough, care and treatment were clearly explained, and they knew what to expect throughout their surgical pathway. People felt supported to make informed choices and were given options regarding their treatment and pain management. Patients told us staff responded promptly when they needed assistance and provided reassurance and emotional support when required. People with additional needs were supported through reasonable adjustments, including communication support, interpretation services, pre-operative visits and personalised care planning. Patients found the service accessible and easy to navigate, were generally satisfied with waiting times and appointment arrangements, and knew how to provide feedback or raise concerns. Feedback from patients was overwhelmingly positive, with satisfaction survey results consistently high and patients reporting positive outcomes following treatment, including improvements in pain, mobility, function and quality of life.